IV Tubing Misconnection Errors Can Result in Serious Injury or Death

Know your legal rights if you suffer an injury as a result of an IV tubing misconnection error that you believe resulted from negligent nursing care.

A tubing misconnection error (tubing mix-up) occurs when nurses unintentionally connect one end of an intravenous (IV) tube or catheter to the wrong tube or device, often resulting in serious patient injury or death.  Nurses should always trace the tubing back to its origin to prevent misconnection errors.

Sample Case:  A 24-year-old woman was 35 weeks pregnant with her second child when she was admitted to the hospital for chronic vomiting, dehydration, and weight loss.  The physician ordered enteral feeding (being fed by a feeding tube that goes through the patient’s nose and ends in the stomach) to help stabilize the woman’s weight and reverse the dehydration until her daughter could be born.  The nurse mistakenly attached a bag of liquid nutrition to a tube that entered the woman’s vein via IV as opposed to the tube in the woman’s stomach, thus delivering the liquid food directly into the woman’s vein.  This had the similar effect of pouring concrete into a garden hose, which caused the pregnant woman hours of excruciating pain.

Both the woman and her unborn daughter died leaving the woman’s first child, a 3-year-old boy, without a mother.

Scope of the Problem

According to the Food and Drug Administration (FDA), The Joint Commission (TJC), and the World Health Organization (WHO)—organizations that advocate for patient safety—tubing and catheter misconnection errors are under-reported despite the fact that many lead to serious injury and death in patients.  Researchers have traced hundreds of deaths or serious injuries to tube mix-ups.  In 2006, a survey of hospitals found that 16 percent of the institutions had experienced a feeding tube mix-up.  Although this statistic is not particularly large, the resulting injuries to the patients were critical.

In an example of a tubing misconnection error that caused a patient’s death, the tubing from a portable blood pressure monitor was mistakenly connected to a patient’s IV line, causing a fatal air bubble.  In a similar case, the air supply hose of surgical compression stockings was attached to the patient’s needleless IV tubing.  In another case, the patient’s IV tubing became disconnected and was mistakenly reconnected to the tracheal cuff in his throat.  The IV fluid flooded the patient’s lungs, and he died.

Causes of Misconnection Errors

Misconnection errors occur when a nurse connects one end of a tube or catheter to the wrong tube or device, such as a blood pressure monitor connected to a needleless IV port.

Other factors that contribute to tubing misconnections include:

  • Hospitalized patients with many unmarked clear plastic tubes running into and out of their veins, arteries, stomachs, bladders, lungs, and skin to help deliver or extract medicine, nutrition, fluids, blood, and gases.
  • Surgical patients can have many of these tubes listed above including additional ones needed to deliver anesthesia to the patient and air to the surgical compression stockings.
  • Tubes that require frequent disconnection and reconnection to decrease the risk of infection to the patient.
  • In regards to enteral feeding, the companies that make the feeding tubes are not necessarily the same companies that make the feeding pumps or liquid nutrition bags. This accounts for a lack of similarity across medical products that are meant to work together.
  • Nursing errors are due in part to poor lighting in the patient’s room at night, fatigue, inadequate training, rotating shift work, time pressure, attempts to use short-term memory recall for large amounts of information, and moving patients to other areas in the facility.

The Problem with Luer-lock Connectors

One tubing or catheter connector that has proven to be especially problematic is the Luer-lock connecting system.  Luer-lock connectors easily allow many dissimilar tubes or catheters to be hooked together, making medication administration into the tubes easier.  The asset that makes the Luer-lock so valuable—easy connection of dissimilar tubes—is also what makes it so dangerous.  In the absence of diligent nursing care, nurses can connect tubes that should otherwise never be connected together, thus increasing the chances of a fatal tubing misconnection error.

Steps to Prevent Tubing Misconnection Errors

Nurses who work with patients that have multiple tubes and catheters must be continuously aware of the dangers of accidentally connecting the wrong tubing or catheter and must take steps to decrease these risks.  Steps to prevent tubing misconnection errors include:

  • Train nonclinical staff and visitors not to reconnect tubing but to seek help from a nurse instead. Only staff that works with tubing on a regular basis should make reconnections.
  • Do not use tubing or connectors that are not specified for the equipment in question.
  • When reconnecting tubing, trace the lines back to their origin and ensure they are secure.
  • When moving a patient to a new area of the facility, recheck the tubing connections and trace them back to their origin.
  • Route tubes and catheters that have different purposes in different directions. IV tubing should be routed towards the patient’s head and tubing that is in the patient’s stomach or intestines should be routed towards the feet.
  • Do not use additional adaptors and connectors in enteral feedings.
  • Label or color-code tubes according to function and alert staff to the labeling system.
  • Identify and confirm any solution that is infused into the patient.
  • Connect all tubing under proper lighting conditions.
  • Minimize nursing fatigue to improve patient safety.

What You Should Do

If you, or a member of your family, are injured due to a tubing misconnection error, write down as much information as possible about the circumstances while they are fresh on your mind. Details like the type of medication or other substance(s) infusing when the error was made, names of the hospital staff on duty, when the mistake occurred, and the type of machines or tubing in use can be crucial in obtaining appropriate follow up care and documenting any potential claim for malpractice. If possible, photograph the injured area (if applicable) and all equipment involved as soon as possible. Clear and up-close pictures of the tubing, catheters, and tubing connections involved can be invaluable in the effort to figure out what went wrong and whether nursing negligence is to blame.  Next, go to the medical records department and obtain your medical records so an experienced medical malpractice attorney can review them to determine if the medical staff followed the appropriate standard of care.  If negligence occurred and caused the injury, legal avenues may be available to recover compensation for losses like past and future medical expenses, disability, pain, suffering, and even wrongful death.

Contact Us

If you suffered an injury on account of an IV tubing misconnection error, contact one of the attorneys at Burnside Law Firm LLP for a free initial consultation to learn more about your legal rights. You may either complete an email contact form and provide us with the details of your claim or call 1-800-569-1937 to speak with one of our attorneys.

Additional References Concerning Tubing Misconnection Errors:

  1. Association of periOperative Registered Nurses (AORN). (2011). Recommended practices for a safe environment of care. In AORN Perioperative standards and recommended practices (pp. 215-236). Denver: AORN.
  2. Beyea, S.C., Simmons, D., Hicks, R.W. (2007). Caution: Tubing misconnections can be deadly. AORN Journal, 85(3), 633-635.
  3. Food and Drug Administration (FDA). (2010). Letter to manufacturers of enteral feeding tubes, healthcare professionals, and hospital purchasing departments. Retrieved August 22, 2011 from, http://www.premierinc.com/safety/topics/tubing-misconnections/downloads/FDA-Enteral-Feeding-Tube-Letter.pdf
  4. Food and Drug Administration (FDA). (2005). Luer lock connections can be deadly.  Patient Safety News. Retrieved August 22, 2011 from, http://www.premierinc.com/safety/topics/tubing-misconnections/downloads/fda-luer-lock-misconnections.pdf.
  5. Gallauresi, B. Eakle, M., Morrison, A. (2007). Misconnections between medical devices with Luer connectors: Under-recognized but potentially fatal events in clinical practice. Safe Practices in Patient Care, 3(2), 1-8.   Retrieved August 22, 2011 from, http://www.premierinc.com/safety/topics/tubing-misconnections/downloads/SafePracticesInPatientCare.pdf
  6. Peterson, C. (2011). Continuum of care. In Perioperative nursing data set: The perioperative nursing vocabulary (3rd ed., pp. 160-164). Denver: AORN.
  7. Peterson, C. (2011). Extraneous objects. In Perioperative nursing data set: The perioperative nursing vocabulary (3rd ed., pp. 165-172). Denver: AORN.
  8. The Joint Commission (TJC). (2008). Enteral feeding misconnections: A consortium position statement. The Joint Commission Journal on Quality and Patient Safety, 34(5), 285-292.  Retrieved August 22, 2011 from, http://www.premierinc.com/safety/topics/tubing-misconnections/downloads/S5-JQPS-05-08-guenter.pdf
  9. The Joint Commission (TJC). (2006). Tubing misconnections—A persistent and potentially deadly occurrence. Sentinel Event Alert, (36), 1-3. Retrieved on August 22, 2011 from, http://www.jointcommission.org/assets/1/18/SEA_36.PDF
  10. The Joint Commission (TJC) and World Health Organization (WHO) WHO Collaborating Centre for Patient Safety Tubing Misconnections. (2007). Avoiding catheter and tubing mis-connections. Patient Safety Solutions, 1(7), 1-3. Retrieved August 22, 2011 from, http://www.premierinc.com/safety/topics/tubing-misconnections/downloads/PS-Solution7.pdf